Provider Demographics
NPI:1609932342
Name:EYE CARE INSTITUTE, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EYE CARE INSTITUTE, A MEDICAL CORPORATION
Other - Org Name:SANTA ROSA EYE PHYSICIANS AND SURGEONS MEDICAL GROUP, A PROF CORP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-546-9800
Mailing Address - Street 1:1017 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6608
Mailing Address - Country:US
Mailing Address - Phone:707-546-9800
Mailing Address - Fax:707-546-4112
Practice Address - Street 1:1370 MEDICAL CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2934
Practice Address - Country:US
Practice Address - Phone:707-585-6110
Practice Address - Fax:707-585-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0399240001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76363ZMedicaid
CA180014574Medicare PIN
CA00G343820Medicare PIN
CA00G493740Medicare PIN
A45905Medicare UPIN
CA180014573Medicare PIN
F13493Medicare UPIN
CACS5700Medicare PIN
CA00G620850Medicare PIN
CA00G608280Medicare PIN
CAZZZ76363ZMedicare PIN
CASD0098570Medicare PIN
0399240001Medicare NSC
CA410043804Medicare PIN
A51347Medicare UPIN
CA180042403Medicare PIN
U25600Medicare UPIN
F12164Medicare UPIN
CA180036143Medicare PIN